Dr Christine O'Malley
It takes a village to rear a child. It takes a village to keep my house and garden going.
When I moved to Dromineer 20 years ago, I was told there were a hundred houses, about half being holiday homes. We’re a small community. The numbers have gone up a bit, but that split is much the same. The summer people say, “Dromineer must be so quiet in winter”. And we residents agree cheerfully.
Within the village, there are some demarcations. A resident complained about badly-parked cars. A neighbour commented that her own brother parked his truck anywhere and everywhere. The answer: He was born in this village. So that’s clear: 20 years or forever, I’ll still be a blow-in.
Down by the lakeshore, there are divisions too.
Dromineer Boat Club is for fishing folk; Mayfly season is serious. Lough Derg Yacht Club is for sailors, like me, and some fishermen too. There’s the Marina and a public harbour too.
But we all hang out in the Whisky Still and the Lake Café, which both serve great food.
In our small community, there are many useful people. We have a couple of judges and a school principal. When Tom got into a battle with An Bord Pleanala, he went to Liz for a legal chat. Noreen has advised on endless school problems over the years. The ex-head of An Taisce lives here too, and a former President of the IMO — yes, that’s me. Another neighbour has a connection to US Immigration at Shannon Airport, which is handy in these troubled times.
They all play a part in village life, but I rely on some other very important people.
Across the road lives Willie, who built my house, taking a long break in Mayfly season. This year, he’s building me a tiny garden house. In the great snow of 2018, Dromineer was cut off from the world. But within the village we had no problems: Willie and his digger cleared the snow from roads and driveways, so Noreen could walk up to my house for coffee, and later we got to the pub for a hot whisky.
Anthony, who plumbed this house, lives round the corner. The day the water tank burst in the attic, and water poured down my kitchen walls and through the light fittings, he was here within minutes.
My Aga is serviced by Jim. He doesn’t bother with appointment times, just calls in on his way home — he lives down by Dromineer Castle. When I dropped the big Aga kettle, and the handle broke off, he fixed that too — all part of the service.
My garden was planned and planted by Ger, whose sister has a holiday house in Dromineer. With a team of helpers, he’s kept it going through storms, snow and sun.
When Donal retired from teaching, his wife volunteered him to walk my dogs. Even though he’s busier than ever, he finds time for them most days and they get so excited when they see him.
Sometimes deliveries need help too.
On Mother’s Day, Annie sent flowers from Cardiff, but the delivery man couldn’t find me. So Biddy hopped in to show him “the doctor’s house” and to confirm they were from “Tom’s daughter”. She has dozens of flower pots outside her own house. A few years ago, on a dark winter’s evening, we were all summoned to the pub to celebrate Biddy’s 90th birthday.
There are some slight problems: village people don’t bother much with schedules, so they can turn up at any time.
I used to tell guests there’s no-one around outside; just a field with bullocks. I don’t say that anymore, since a friend took me a bit too literally. Fresh out of the shower, she threw up the window-blind of the downstairs guest room… just as a lawn-mower was being pushed past her window.
Bank holidays have no relevance either.
On New Year’s Day, my sister and I were having a late breakfast in our PJs when a truck pulled in. It was just Sean delivering a load of wood. He’s another Mayfly man. He once told me a story about ghillying for some useless people; they nearly capsized his lake boat and the shock of it set off his intra-cardiac defibrillator.
At the June weekend, I was at Bloom helping a neighbour sell gardening gear. Surprisingly, a career in hospital medicine has made me a star seller of hats and gloves. Noreen called up each day to feed the cat. Ger and friends were in the garden cutting back shrubs. Then Donal checked on my flower pots, and phoned me.
I’d left my keys hanging in the back door. That’s village life. That’s Dromineer.
he referendum pushed CervicalCheck off the front pages for only a short time. Even while it was rumbling away in the background, it was rumbling in my head too, stirring-up old thoughts.
When I was 12, people didn’t believe me when I told them of ideas I had years earlier. Being a peculiar kid, I decided to keep a diary to show myself that I really did have such thoughts.
Now I write columns for Mindo instead. I can look back and see my thoughts laid out in black and white. Oh dear! I can also see when I’m repeating myself.
What follows here is conjecture and opinion, not necessarily fact.
Since the CervicalCheck story broke, there have been calls to reinstate the Board of the HSE. Interesting. It brings me back to the foundation of the HSE.
When Mary Harney became Minister for Health, I felt as if I was ‘marking’ her, as on a sports field. I listened to her words: More hospital beds and consultants needed, but silently, I added ‘in the private sector’ as co-located private hospitals were announced. I looked at what she did — close cancer units in public hospitals, while welcoming private cancer units.
At that time, the CEO of the HSE said more private hospital beds were not needed and the ceiling on recruitment was a significant problem. He was publicly reminded that the role of the HSE is ‘operations’. ‘Strategy’ is the job of the Department of Health.
The health Budget increased rapidly.
It was all very clever — but that’s just my opinion. If money pours into healthcare, but you’re not allowed recruit staff, the only way to develop services is to privatise.
So the NTPF diverted patients from public waiting lists to private hospitals. And commercial companies lined-up to take on chunks of Irish public hospitals.
Companies looked at outsourcing whole radiology departments, or running minor injury units in public hospitals. There was talk of Quest Diagnostics running ‘cold’ laboratories for the whole country.
In the end, the financial crisis killed off all that commercial enthusiasm. We’re left with some oddities from that time and the contract for cervical smears is one.
The HSE Board was in place when CervicalCheck used a public tender for the cervical smear contract — an unusual step at the time. That first contract went to Quest Diagnostics; all smears from Irish women were sent to the US — another unusual step. (A second US lab and the Coombe were added later.)
I was quite distressed about it at the time, but not surprised. It fitted with my view that cancer care was to be outsourced to the private sector as much as possible. I knew several Board members personally, but they never seemed anxious to talk to me!
Back to the present.
Recently, Fergus Finlay said he couldn’t work out what sort of a corporate entity CervicalCheck is. I’ve heard it’s an ‘independent business unit’ within the HSE. That fits with privatisation; it could be cut loose at a suitable time.
I watched a Health Committee meeting on TV. Stephen Donnelly said that medics were involved in the tender result, so outsourcing to the US was not a political decision. That’s a bit naive from a former management consultant. He should know that a tender can be designed to pre-select the outcome.
The CervicalCheck tender had three elements. Accreditation was required; Irish labs had almost completed theirs.
Cervical smears had to be turned around very quickly. Irish labs had long delays and the ceiling on recruitment prevented them from fixing the problem.
The third item was cost. Ah yes, cost. When I heard the US lab was one-third of the price of the Irish labs, my Trinity MBA training kicked in. How could this be possible?
I’ve heard it’s because of pension costs, or because Irish lab scientists are more highly trained than US smear-checkers, and therefore more expensive. But I really can’t see how an American lab could be so cheap.
Then I learned there was a sister lab in Mexico. Ten years on, we know that outsourcing to the UK is allowed under the contract. I’d love to know if any smears went to South America.
And it was all done under the governance of the Board of the HSE.
I wonder who designed the tender? Did the HSE Board sign-off on it? Maybe Board members had concerns about sending Irish cancer tests overseas, but a tender result is legally binding.
There’s no open disclosure for commercially-sensitive information, so we’ll probably never know.
That’s just my opinion.
“It always rains on my birthday,” I said, aged 10. A kindly adult answered, “it only seems that way”.
To me it was a truth, an observation. I decided to make a mental note of the weather on my birthday each year. After 10 years of rain on 1 May, I felt the case was proven.
I take a long view and I respect evidence.
When the CervicalCheck story burst into our lives, my thoughts went back 10 years. That was a strange time.
US firms lined-up to replace public services but the details were secret, because it was “commercially-sensitive information”. The new consultant contract was clearly based around co-located private hospitals, but doctors’ concerns were dismissed as “vested interests”. Health watchdog HIQA was set up and had no oversight role in the commercial sector.
Ten years ago, the Mid-West was a pilot for outsourcing cervical smears to the US. My GP friends said that, compared to the Irish hospital labs, there were too many low-grade abnormalities reported. Lots of anxious women had to be referred to hospital clinics, but were in fact healthy.
We know now that the head of quality assurance for cytology also had concerns. He had evidence that high-grade abnormalities were not being picked up in the US; cancers would be missed.
This is not my area of expertise, but like everyone else, I’ve had the radio on constantly and I’ve bought stacks of newspapers.
I’ve also looked at any data I can find, including Programme reports from the early years. Quality assurance is mentioned constantly. However, CervicalCheck seemed to regard lab accreditation as a guarantee of quality.
I don’t think a doctor would get away with that in a court case, or in front of the Medical Council. We’re expected to look at evidence. Health administrators can’t, so they use external measures of quality.
I remember thinking that CervicalCheck was set up like a postal service, sending smears to the US and results to GPs. Issues such as quality and liability were outsourced with the contract. The US doctors reporting on Irish tests didn’t even have to be on the Irish Medical Register.
In those early reports, over-reporting of minor abnormalities is noted. I didn’t see efforts to address the more worrying issue — under-reporting of major abnormalities.
As the days went by, personal tragedies emerged one by one, each woman, each family.
The media pointed at doctors for not telling patients; the politicians said mandatory disclosure was the answer. I wondered about lab quality.
Very slowly, information is coming out.
In 2014, an audit was done of 1,480 women who developed cancer since the start of the Programme. When those smears were reviewed, 209 cases should have been reported differently. That’s 14 per cent.
Yes, the test is imperfect. And mistakes happen too. The issue is how frequent those mistakes are, and how bad, and whether there is variation among the labs.
Why wasn’t the audit done before 2014? It should be routine in a national screening programme. Maybe that’s “commercially sensitive information”.
We heard about the US labs: Legal case, gagging orders, legal letters preventing disclosure.
One US company sent Irish smear tests to a sister lab in the UK. The lab is accredited and it’s all within the terms of the HSE contract, but the effect is a fragmented system. Questions are being asked about the oversight by doctors, and whether Irish smears have been sent to labs anywhere else.
Then there’s the debate about cost.
When Vicky Phelan told us her shocking story, she pointed the finger of blame at then Minister Mary Harney for outsourcing cervical smears to the US.
I remember Mary Harney saying we had to, because the US lab was one-third the price of the Irish labs. Most people thought, ‘rip-off Ireland again.’
To me, it simply didn’t make sense. How could an American lab be so cheap?
That was the time when Mary Harney said cancer units in public hospitals around the country had to close because patients deserved a centre of excellence.
Cost versus quality: Are the rules different for commercial contracts?
On Morning Ireland, a senior lab scientist said one lab appears to be finding fewer high-grade abnormalities. We know it’s not the Coombe.
If the labs differ in quality, surely Irish women deserve to have their tests read in a laboratory centre of excellence.
I really enjoyed the IMO AGM this year. It’s funny, because I went with very low expectations. Since leaving work, I feel rather irrelevant. And yet my views are as fiercely held as ever.
But the AGM was back to ‘our’ hotel, Hotel Europe in Killarney. The location is stunning. Simply looking across the lake at mountains is good for the soul. Add in great food and lovely staff and it’s the place to be. It would be a shame to miss it.
Annie (stage manager) booked in immediately – it’s her favourite hotel.
On the way down, I heard the soothing, measured tones of Peadar Gilligan (incoming President) on the news. It’s an IMO tradition.
Shortly after we arrived, I got a message from The Irish Times. They’re printing my article the next day! It’s a light-hearted look at trolleys. (Yes, seriously.)
I feel better. Then I start to worry. What will the emergency medicine crowd think of my article? I nab Peadar – he likes it. Whew!
I have another prop with me: The answer to a parliamentary question, which confirms that the HSE have no data (their emphasis) on trolley patients, as regards age or illness. It’s because HIPE coding is not done unless the patient physically moves to a ward. How can the HSE solve the trolley problem if they know nothing about the patients?
Peadar suggests I use it during the afternoon motions session.
By now, quite a crowd has gathered, including a healthy turn-out of articulate NCHDs. It’s great to catch up with old friends, mostly people I meet only at the AGM. Later, the hall is packed for the panel discussion on Sláintecare.
The weather was not welcoming in Killarney at first. The mountains were greyed out by the rain. Storm winds herded chairs and tables along the terrace as Matt (psychiatrist, musician and MC extraordinaire) gave a talk on depression. Was nature in sympathy?
But the IMO always brings the sunshine.
I skipped the talk on GDPR and sat outside, watching the sun chase the last clouds from the mountain. Strangely beautiful music came from a balcony overhead. I looked up and saw Larry (GP and piano player) also listening. Roisin Dubh he called down to me. So we sang a few lines “A Roisin, na biodh bron ort…” as Ina (Chair of the Public Health Doctors) played the uileann pipes. Future committee meetings may be very interesting.
Maybe because of the setting, I fell into a number of remarkable and highly personal conversations with people I don’t know very well. It reminded me that we can never guess what troubles are going on in the homes and lives of colleagues.
Appropriately, there was a session on burn-out among doctors. The rates are astonishingly high. That was highlighted at the consultant national meeting, when two doctors referred, almost casually, to their experience of severe burn-out and how poorly their employers dealt with it.
As I attended debate sessions and listened to the life of a coroner, Annie was having her own AGM. There were long conversations with Niamh (artistic director) about funding for the arts in Wales and Ireland and discussions on plays with Aoife (theatre director) as well as getting advice from Matt (superhero) on handling an audience.
Meanwhile, Stephen Donnelly (FF health spokesperson) talked with Asam (surgeon and health realist) and me about medical employment and the peculiarity of labelling graduates in a negative manner as ‘non-consultant’. It’s interesting to get such a different perspective.
Later I met Minister for Health Simon Harris. He has a remarkable memory. We took up the conversation where we left off last year – beds and trolleys, of course. He wants to open beds quickly and can’t understand why so many were closed. I said if it’s very clear that beds are coming, morale might start to improve.
We live in hope, and there’s been very little recently.
There were late nights and some drink too. As I queued at the bar behind Frank Murray (RCPI Alcohol Bill advocate) I comforted myself that Joe (IMO Alcohol Bill advocate) told us women over-55 are not the problem as regards alcohol in Ireland. Great!
Very late on the last night, when even the IMO staff were off-duty, I sat with the media pack in the bar. Priscilla (Mindo) decided it was time to set me up on Twitter. The Irish Times and RTÉ were shaking wise heads, saying “Twitter at 3am – this won’t end well.” But it’s ok, I intend to lurk for a while. So we ordered another round and continued.
Annie and I had a weekend of fun and good company and a varied programme. Thanks to team IMO for a great AGM. And a big thank you to the kids who campaigned relentlessly to bring us all back to Hotel Europe.
During the Great Snow, I went through the snippets and articles of medical interest sitting on my kitchen table. Some are from the Medical Independent; others from newspapers. The best get stuck under fridge magnets, along with my favourite Mindo cartoons.
Let’s start with a lawyer who said the relationship between doctor and patient is “not merely a legal relationship, but one based on trust” and that a system of medical regulation that undermines trust “has got to be wrong”. Yes, yes, yes. It’s lovely to have new voices speaking up for what we do.
It ties-in nicely with a book review on unconventional treatments, which reminds the GP writer: “Never underestimate the power of the doctor themselves as the therapeutic agent.” I think modern hospitals ignore this part of patient care, as if it doesn’t matter.
The thing is, it’s not just GPs who are therapeutic agents. I didn’t know studies have shown “the biggest single factor that influences how happy a patient is after a knee replacement is how nice the doctor is to the patient”. Of all hospital specialties, orthopaedic surgery looks purely technical. Clearly, it’s not.
I find I learn a lot about our health system from individual patient experience, but consultant colleagues warn me: “That’s just anecdote, not evidence.” I’d have been at home at the meeting of medical story-telling in Galway. Yes, stories help “make sense of medicine’s complexities and uncertainties” and help maintain “a sense of humanity and what’s important”. Evidence-based practice has its place, but don’t leave people out.
An item that will live on my fridge door, for a while, is from the RCSI Millin Meeting. A UK Professor said specialism may be causing harm. It “breaks down continuity of care” and leads to endless referrals; professionals are reticent to make decisions outside their specialty, which leads to “paralysis in the system”.
I didn’t think I’d see that said in my professional lifetime, and by a surgeon. It’s the story of my life as a consultant, especially in recent years. A hospital admission used to be a one-stop shop to get everything sorted quickly for a patient. Now it’s just the prelude to months of clinics and scans and scopes.
The Professor also said that specialism leads to “medical tribalism” and specialists dominating guidelines. I hope that’s not what lies behind the loud campaign to “streamline” trauma services, which is covered in several newspaper cuttings.
Based on the horrors of reconfiguration in the Mid-West, here’s what will happen.
The new trauma centres will be overloaded with patients and trolleys; they’ll wonder what went wrong, how could the data lie? The HSE won’t believe them and will claim there are only two extra admissions per night. Referring hospitals will discover that patient transfers require complex decision-making and are very time-consuming. The ambulance service will fall further behind on their HIQA targets.
Please, please, do it in Dublin first. There’s some slight chance the problems will be noticed before it’s imposed on all of us.
If ‘reconfiguring’ in Dublin causes problems, maybe The Irish Times and Sunday Business Post might notice that the extreme trolley crisis in the Mid-West was caused by reconfiguration. It might dawn on them that “reconfiguring” services in Portlaoise will severely damage all nearby hospitals.
Meanwhile, an Irish Times editorial calls for trauma care on fewer sites, just like cancer services were “centralised in eight sites” a decade ago. But that’s not what really happened: as public services closed, private centres opened. The then Minister for Health Mary Harney even cut the ribbon on one such unit.
A Sunday Business Post article says the Government has refused to centralise services, “which would help reduce running costs”. I am not aware of any evidence that cost will be reduced.
If this comes as a surprise, look at the private hospitals — they have remarkably small staff numbers. They don’t talk about ‘economies of scale’, and for good reason. An acute hospital is not a manufacturing plant churning out pins, in the Adam Smith model, or complex items, such as cars. Acute care is more like crash repairs. It’s messy, with highly-individualised, bespoke solutions for each patient.
In economic terms, the true problem is that large hospitals have higher fixed costs than smaller units. That makes every case expensive, even the simple ones.
“I think sometimes we take an engineering analysis to the health system”, says Dr Mike Ryan from the World Health Organisation, when actually, health is “very organic”.
My final quote is from business guru Peter Drucker: “Large healthcare institutions may be the most complex organisations in human history” and “even small healthcare institutions are complex, barely-manageable places”.
I agree. That’s another one for my fridge.
Dr Christine O’Malley discovers hidden waiting lists in the NHS and concludes that there’s no place like home
Trolley crises and bed shortages bring about a sense of frustrating déjà vu for Dr Christine O’Malley
A family member’s struggle with anxiety brings into focus the problems of student life for Dr Christine O’Malley
Dr Christine O’Malley on cutting through the ‘HiPE’ and unspinning health service codswallop
Dr Christine O’Malley on her annual pilgrimage to the Dromineer Literary Festival and the connections it inspired
Dr Christine O’Malley ponders the big problems and calls for a reality check in our hospitals and Garda management
It’s remarkably hard to notice or recognise a sensory experience that you don’t share, writes Dr Christine O’Malley